Triage Checklist for Nurse

Triage is a system developed by French doctors in World War I to manage situations in which there are more patients than doctors. The name comes from the French word "trier," meaning to sort into groups. The original groups were (1) those who will probably live even without medical attention, (2) those who will probably die even with medical attention, and (3) those who can be saved by medical attention. Group 3 was treated first.

Modern Triage

• Modern triage is usually performed by trained triage nurses who use a triage checklist. These checklists were prepared by doctors and have been tested for years in emergency rooms and disaster situations. One simple triage system is the Simple Triage and Rapid Treatment system, which uses checklists of symptoms and visible injuries to place patients in one of four categories: (0) deceased or unsavable, (1) needs immediate attention, (2) needs attention as soon as possible, and (3) patients with minor injuries who can wait until more seriously injured patients are treated. Patients receive treatment in the order 1-2-3.

Emergency Room Triage

• ER triage is usually the most sophisticated form of triage because of the relative abundance of medical professionals and the availability of medical equipment. One system that is widely used in American ERs is the Injury Severity Score system, which assigns each patient a score of 0 to 75. The body is divided into three regions: head and neck, trunk, and skin and extremities. A detailed checklist of injuries covers each region. Some items on the checklists automatically set the score to 75, such as "not breathing." In ISS the triage status is continually updated as the patient waits for treatment. The system includes "triage tags" that are attached to the patient and can be updated easily.

Disaster Triage

• Triage after disasters such as earthquakes, hurricanes and train wrecks often includes a system of color coding. The code changes in different countries and regions but three colors are almost universal: black indicates dead, red indicates that the patient needs immediate attention, and green indicates that a patient has only minor injuries. Sometimes the coding medium is as simple as rolls of colored tape. A person with some medical training--and a checklist--goes among the injured and wraps a strip of tape around the leg of an injured person. The checklists for disaster situations tend to be simple and omit injuries that might be hidden by clothing. Most ambulances are required to carry disaster triage checklists and color coding material.

Telephone Triage

• Telephone triage means determining how seriously injured someone is over the telephone. This is especially difficult because the nurse cannot see the patient and the injured person may not be the one on the phone. Telephone triage is often used to determine a caller's mental state--how dangerous or suicidal a person is.

  As in other forms of triage, the primary tool is the triage checklist. For telephone triage, the checklist takes the form of a list of questions to ask the caller. An accompanying list of answers assigns a score for each. By asking the questions and recording the scores of the answers, the triage nurse can place patients in the proper category.